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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700436
Report Date: 06/28/2023
Date Signed: 07/06/2023 08:52:49 AM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 07/06/2023 08:52 AM - It Cannot Be Edited
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:GM ARF 2FACILITY NUMBER:
392700436
ADMINISTRATOR:MATA, CESAR YFACILITY TYPE:
735
ADDRESS:2423 COURTNEY WAYTELEPHONE:
(916) 706-8427
CITY:STOCKTONSTATE: CAZIP CODE:
95210
CAPACITY: 4CENSUS: 0DATE:
06/28/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:20 AM
MET WITH:Danilo Mabalot - Direct Care StaffTIME COMPLETED:
09:20 AM
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Licensing Program Analyst (LPA) Ruth Wallace conducted unannounced required one year annual inspection visit. LPA met with direct care staff and explained the purpose of the visit.

LPA Wallace and direct care staff inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, living area, common TV area, and outside backyard of the facility to ensure compliance with Title 22 regulations. Facility is a four bed facility with a current census of zero. Facility has three bedrooms. one bedroom has a private bathroom. Dining area is shared with kitchen space. The facility submitted a LIC 808 mitigation plan, which was approved. The facility has a designated infection control lead.

Water temperature reads 110.6*F in the bathroom and room temperature reads 75*F. Resident rooms were sanitary and had the required furniture and furnishings. The facility common areas were clean and furnished. Smoke and carbon detectors were in good repair. Fire extinguisher was last inspected on March 8, 2023. Facility has an emergency food and water kit.

Per California Code of Regulations, Title 22, no deficiencies were observed during this visit.

Exit interview was held and a report was given to direct care staff.

SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Ruth Wallace
LICENSING EVALUATOR SIGNATURE: DATE: 06/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/28/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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